Please be sure to number each attachment page (e.g., Page 2 of 3, Page 3 of 3, etc.). 877.502.6272. www.wageworks.com. Claims Address: WageWorks, LLC. Administrators please use Managemyspendingaccount.wageworks.com for your site login. Using your Mobile Device With the EZ Receipts mobile app, you can file and manage your reimbursement claims on the spot, with a click of your mobile device camera, from anywhere. Based on IRS guidelines, claims submitted more than 180 days after the period for which the expense was incurred will be denied. www.wageworks.com Pay Me Back Claim Form INSTRUCTIONS FOR COMPLETING CLAIM FORM PLEASE READ BEFORE SUBMITTING YOUR CLAIM FORM Your claim is important. Your Payment Options. NO RECEIPT CERTIFICATION to complete your claim. Reimbursement is by direct deposit or check. • New York State allows a runout period to submit claims after the plan year ends. DCFSA for individuals. • File claim online for faster processing: Log in to your account at participant.wageworks.com to submit your claim electronically. CLAIM FORM & FILING INSTRUCTIONS On the reverse side of this page is a claim form. Complete a separate form for your spouse and/or covered dependents. Unauthorized use of this system is prohibited and may result in revocation of access, disciplinary action and/or legal action. I also understand failure to repay the Plan could result in … You can manage and check on your account through WageWorks online or over the phone. • The standard mileage rate reimbursable for use of an automobile to obtain medical care is subject to change by the IRS annually. Reimbursement Options through WageWorks. Health Reimbursement Arrangements are employer-owned accounts that are used by employees for specific medical expenses. To ensure we are able to process your reimbursement, please fully complete the attached WageWorks Pay Me Back Claim Form. 2. Tips For Faxing • Do not use a cover page when faxing the claim form and documentation. If you enroll in a Health Care FSA, you will be issued a WageWorks debit card that may be used instead of cash or credit at health care providers and pharmacies for eligible services, goods, and prescriptions. DEPENDENT CARE ACCOUNT PAY ME BACK CLAIM FORM TOLL-FREE FAX: 877-782-8889 E-mail: claims@takecareclaims.com Or mail to take care by WageWorks, PO Box 14054, Lexington, KY 40512 I have not/will not seek reimbursement of this expense from any other plan or party because I: 1) pay for the premiums through withholding, 2) have paid for the premiums out of pocket. The Medicare reimbursement form, also known as the “Patient’s Request for Medical Payment,” is available in both English and Spanish on the Medicare website. HEALTH CARE ACCOUNT PAY ME BACK CLAIM FORM TOLL-FREE FAX: 877-782-8889 E-mail: claims@takecareclaims.com Or mail to take care by WageWorks, PO Box 14054, Lexington, KY 40512 The company reserves the right to monitor and review user activity, files and electronic messages. Details: Pay Me Back claim form through the WageWorks (“Reimbursement Accounts”) web page and follow the instructions for submission. Your claim form is … A WageWorks® Health Reimbursement Arrangement (HRA) is an employer-sponsored benefit to reimburse a portion of your eligible out-of-pocket medical expenses, such as deductibles, coinsurance, and pharmacy expenses. Mobile App For Reimbursement Accounts. Find all the details — and instructions on how to set up a Medicare Reimbursement Account online — here. Reimbursement Request form is required for each year. Box 34700 Louisville, KY 40232 Overnight Mail: 5200 Commerce Crossings, Suite 100 provide any form of receipt. Complete a separate form for your spouse and/or covered dependents. Direct deposit is the quickest and safest way to get reimbursed for your eligible healthcare expenses. TOTAL THIS FORM Retiree Birth Date (MM/DD) Employer Name Health Reimbursement Arrangement (HRA) RETIREE Pay Me Back Claim Form DO NOT USE A FAX COVER SHEET to ensure speedy processing. mymra.wageworks.com and select “Direct Deposit Sign-Up” from the left-side menu. www.wageworks.com WW-HRA-RT-PMB (Nov 2010) TOLL-FREE FAX: (877) 353-9236 Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512 1. • File claim via fax or mail: Claim details may be entered online and a completed form may be printed and faxed or mailed with documentation. To use EZ Receipts: • Download at There are three ways to submit a Dependent Care FSA claim: Use the FSAFEDS app to have the dependent care provider certify the service by providing a signature on your mobile device. • Fax: For faster service, fax your claim to 877-782-8889. Complete the online claim form and attach an image of your receipt in JPG, PDF, TIFF, or GIF format. Click here to file a claim for Health Care Reimbursement Account expenses.. Fill in the total annual or monthly/quarterly amount of your Medicare Part B payment.